Validation of the Clavien–Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel

Abstract

ContextSince 2012 uniformed reporting of complications after urological procedures has been advocated by the European Association of Urology (EAU) guidelines. The Clavien–Dindo grading system was recommended to report the outcomes of urologic procedures. ObjectiveTo validate the Clavien–Dindo grading system in urology. Design, setting, and participantsMembers of the EAU working group compiled a list of case scenarios including those with minor and major complications. A survey was administered online via Survey Monkey to the members of EAU committees for the appropriate grading according to the Clavien–Dindo classification of surgical complications. Scenarios with intraoperative complications were intentionally included to assess respondents’ awareness of the Clavien–Dindo applicability. Outcome measurements and statistical analysisSurvey data collected were used to calculate agreement rates and to estimate the overall inter-rater agreement on all cases using Fleiss’ kappa (κ). Differences in agreement rates for each scenario among groups with different criteria about the system were estimated using the chi-square test. Results and limitationsEvaluable responses were received from 81 out of 174 invited raters (46.5%). Of them 56.9% believed that the Clavien–Dindo system was adequate for grading postoperative complications. The agreement rate was over a score of ≥80% in nine cases, 60–79% in 10 cases, 40–59% in 14 cases, and <40% in two cases. Interestingly, the agreement rate on the nonapplicability of the Clavien–Dindo system was quite low, ranging from 27.5% to 67.2% (κ=0.147). Being a resident rather than a specialist affected only the distribution of agreement rates in case 1 (ie, score IIIb: 83.3% vs 94.1%). Being an academic or having affiliation did not have any impact on the distribution of agreement rates in all cases but one. ConclusionsThe Clavien–Dindo classification is a standardised approach to grade and report postoperative complications in urology and should be used systematically. However, it does not apply for intraoperative complications, and there is a need for an additional tool. Patient summaryA rigorous methodology is mandatory when surgeons report about complications after surgery. In this study, the European Association of Urology Guidelines Panel has validated the use of the Clavien–Dindo grading system in urology.